fading memories

Safer environment, better therapy for Alzheimer's patients

Mary Hardy

by Jan Elkins

"You know I have Alzheimer's, don't you?" asked Mary Hardy, 85, looking wistful. "It isn't contagious, though; you can't catch it if you touch me.

"It's just that I don't remember things anymore," she added.

A lovely woman with clear, blue eyes, beautifully coiffed, silver hair and a contagious smile, Hardy was born in 1913 in Troope, Tex., a small town 40 miles east of Tyler. She was once dean of the nursing school at Baylor University in Waco.

"I always wanted to be a nurse, even when I was a small child, and I never did change my mind," she stated. "My family lived in the country, and if we found an injured bird or another animal that needed care, I was there to help. If I could just help something that was hurt or sick, I was happy.

"Now, when I look back on my life and think about all that I have accomplished, I wonder how I did it--perhaps because I wanted to do it," she said smiling. "I just had to get my nursing diploma and, once that was accomplished, I just had to go on and get my baccalaureate."

After she received her degree, Hardy worked for Baylor Hospital in Dallas. Later, she married a dentist and the two health care professionals had a family. Unlike most women before World War II, Hardy juggled the duties of homemaker and career.

Hardy is articulate, considering the disease that is ravaging her brain and her body, but she sometimes becomes confused. She retired about 20 years ago, but when asked how long she has been retired, the 85-year old responded, "Oh, three or four years."

Villa Serena, an Alzheimer's treatment facility with a 36-resident capacity, is nestled in the hills of north central San Antonio. Hardy lives there with 16 other residents, ages 57 and older. Her room is more like a bedroom/ sitting room combination in a middle class home than a room in a health care facility. She can relax in a familiar easy chair, be surrounded by pleasant colors and family mementos, and be cared for by professionals who are versed in state-of-the-art treatment methods for Alzheimer's patients.

Dr. David Sherman

"We are using a social and behavioral approach to treat patients at Villa Serena," said David E. Sherman, MD, professor and head of the neurology division in the department of medicine at the Health Science Center. Dr. Sherman is also chairman of a committee that plans and institutes the best possible care for patients living at the nearby facility.

Other university faculty members on the committee are: Raymond A. Faber, MD, associate professor of psychiatry and staff physician for the South Texas Veterans Health Care System; David V. Espino, MD, associate professor of family practice; Helen S. Mayberg, MD, associate professor, and Diane H. Solomon, MD, clinical assistant professor, both in the department of medicine; and Mary Ann Matteson, PhD, RN, Thelma and Joe Crow Endowed Professor, department of chronic nursing care.

The first of several Alzheimer's treatment centers to be built throughout the United States by University Eldercare, Villa Serena is designed to treat patients in a safe, comfortable, homelike environment. "The entire facility is committed to the concept of treatment by interaction with the patient and by behavior modification, as opposed to medication or chemicals alone," Dr. Sherman said.

Beyond providing optimal care, Dr. Sherman is principal investigator on research projects seeking causes of Alzheimer's. "There do seem to be some purely genetic reasons why people develop this disease," he said. "One of the strongest hints that Alzheimer's might be genetic is that children with Down's Syndrome develop the chemical manifestations and the neuropathology of the disease. But this disease isn't determined by a single gene--there are multiple genes and multiple factors that must be present for a patient to develop Alzheimer's.

"It is now possible to determine the history of vascular factors associated with diseases and, because some of the neuropathological changes in the brain concentrate around blood vessels, it is thought that there also must be some vascular component present for a person to have Alzheimer's," Dr. Sherman noted. He added that people with vascular dementia do not necessarily have Alzheimer's, and patients with Alzheimer's do not necessarily develop vascular dementia.

Scientists also have identified some of the chromosomes associated with Alzheimer's. Dr. Sherman explained, "We can send blood from family members of these patients to a laboratory. If two alleles [genes containing specific inheritable characteristics for a disease] are identified, there's a 95 percent chance that person will develop Alzheimer's."

The researcher went on to explain that genes mutate, and some Alzheimer's probably is caused by a genetic mutation, perhaps in sporadic form. "Over the years," he continued, "there has been a variety of literature describing various possible causes. Aluminum was one. Later, this theory was dismissed; although, when rats are exposed to aluminum they develop symptoms of Alzheimer's.

"We all have some loss to our immune systems as we age, and this results in the breakdown of brain cells, which may be caused by environmental influences. But this hasn't been proven," Dr. Sherman concluded.

Another Health Science Center committee member involved with Alzheimer's patients, Dr. Espino, agrees with Dr. Sherman's assessment that Alzheimer's isn't necessarily inherited.

"Researchers know that Alzheimer's isn't an inherited disease, per se," Dr. Espino said. "Dementia is the most prevalent organic disease seen among the older population, and Alzheimer's is the most common cause of dementia."

Almost 50 percent of the patients who have dementia also have an underlying confusion characterized by disorientation, alterations in their sleep patterns and, sometimes, hallucinations, according to Dr. Espino. "Twenty to 30 percent of these patients will die from Alzheimer's or a related dementia," he stated.

Dr. Espino prescribes three medications, donepezil, rivastigmine and metrifonate, for dementia and Alzheimer's patients. "Since these medications are from the same class, there are limited differences between them," he said. "Their purpose is to increase neuron function in the brain.

"We know there is no cure for Alzheimer's, but with donepezil, rivastigmine and metrifonate the disease can be stabilized for a year or longer," he continued. "Then, perhaps next year another drug will be discovered that will lead to a cure.

"These drugs have few side effects, unlike tacrine which caused major problems such as nausea, vomiting, gastrointestinal distress and diarrhea," Dr. Espino explained. "Donepezil, rivastigmine and metrifonate have replaced tacrine as the medicines of choice."

In addition to medication, some Alzheimer's patients are treated with behavioral modification. "In our early research, we began to see a couple of patterns in relation to behavioral symptoms," said aging specialist Dr. Matteson. "First, we realized that many of these behaviors seem to occur because too much or too little is expected from these patients and this agitates them. If too little is expected, they don't have enough stimulation. When too much is expected, they can't complete the task assigned to them, and this upsets them. By intervening at the appropriate level, we minimize these frustrations.

"Also, we observed that as this disease progresses, patients regress socially as well as physiologically. Their behavior regresses through normal stages of human development, so that eventually they become like toddlers and infants in their cognitive abilities," Dr. Matteson continued.

"Levels of cognitive development are identified according to studies of Dr. Jean Piaget, a Swiss psychologist," she said. Dr. Piaget, who died in 1980, was a world-renowned psychologist. He provided understanding of how a child's thinking differs from an adult's, and of how children learn, added Dr. Matteson.

"Dr. Piaget's teaching strategies were based on the acquisition of skills learned at certain levels," Dr. Matteson explained. "In normal development, from birth to 2 years of age, an infant goes through the sensorimotor stage. From ages 2 to 7, a child goes through the peroperational stage and learns to speak, to be content, to walk and to play.

"From age 7 to adolescence, a child develops concrete operations--he or she begins to develop logical thinking," she continued. "Most kids are rule oriented during these years, and reading and writing skills are developed. After age 12 abstract thinking evolves.

"As Alzheimer's disease progresses, these stages are reversed; in the final stage of regression, patients lose their ability to walk and to speak," she said. "Once we have identified the patient's developmental level, we can initiate a care plan for every activity based on his or her abilities," she stated. "During the last few years, we have been able to significantly decrease problem behaviors, such as pacing, agitation and so forth, that are difficult for caregivers.

"Just as importantly, we also have been able to decrease neuroleptic medication [drugs that produce symptoms resembling diseases of the nervous system], such as Haldol and Mellerol, which have many side effects," Dr. Matteson added. "We have been very pleased with the results."

Because they help soothe Alzheimer's patients, rocking chairs are provided at Villa Serena. "Rocking also helps elderly patients retain their balance, and this is a big plus," she said.

"A number of activities, such as Bible study and hymn or other song singing, also help tremendously. People seem to be able to remember music, even if it is from early childhood," Dr. Matteson concluded.

While Health Science Center researchers seek cures for Alzheimer's, the disease's victims at Villa Serena will continue to receive the highest quality care. "This building has been designed to help residents retain their cognitive functioning," stated Lisa Bishop, vice president for marketing at the facility. "Vibrant colors are used on the walls, carpeting and doors as guides. The building has landmarks that assist residents in finding their way, and sitting areas or homelike places that help them feel comfortable."

Arrow Read about "Alzheimer's disease predictors"

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